Obstruction for Certified Emergency Nursing (CEN)
Included In This Lesson
Outline
Obstruction
Definition/Etiology:
- Chronic obstructive pulmonary disease: persistent airflow obstruction due to abnormalities in alveoli and airways, usually caused by exposure to noxious particles and gasses.
- Chronic bronchitis: chronic productive cough for 3 months in each of 2 years, in patients without other causes like bronchiectasis.
- Emphysema: abnormal and permanent enlargement of the airspaces distal to the terminal bronchioles that is accompanied by destruction of the airspace walls, without obvious fibrosis.
- Asthma: chronic inflammation with airway hyperresponsiveness and widespread airflow obstruction within the lung, often reversible either spontaneously or with treatment. Can be exercise-induced, particularly in cold air.
Pathophysiology:
- Chronic inflammation is a hallmark of these diseases. Increased mucus production occurs as well as hyperactivity of cells that fight infection. Allergic mediators play an active role, especially in asthma. In emphysema, destruction of alveoli occurs, and surface area for gas exchange diminishes.
- Stridor is an acute, transient sign of upper airway obstruction from edema, foreign object, infection, allergy, smoke inhalation, etc. It is high-pitched and heard best over the neck.
- Alveolar destruction in emphysema causes loss of spongy recoil in the lungs. This loss of elasticity causes airways to close early during exhalation. This traps air distally in the lungs.
- High CO2 levels in the blood are called hypercapnia. Our drive to breathe is normally based on CO2 levels in the blood. When high, we are triggered to breathe. In chronic pulmonary patients, this can change, and giving them too much oxygen can lessen their drive to breathe. Patients can develop acute hypercapnia, or acute-on-chronic hypercapnia.
Clinical Presentation:
- Exertional dyspnea is the earliest symptom
- Dyspnea at rest develops later
- Chronic sputum production
- Chronic cough
- If wheezing/stridor, look for other s/s systemic allergy
- Doorway assessment: are they toxic? (infection)
- If stridor, assess for aspiration of foreign object
- Chest tightness (less common)
- Tripoding?
- Assess sputum. Color? Frothy?
- Assess work of breathing
- Quiet/focused/nervous vs agitated/frantic
- If sluggish, sleepy, or agitated, consider high CO2
- If home O2, increased AP diameter, clubbing of fingernails, etc, consider chronic CO2 retainer
- If they get quiet, pay attention. Are they moving enough air to wheeze?
Collaborative Management:
Testing:
- Labs: CBC, BNP, CMP, ABG, possibly Alpha 1 antitrypsin
- Pulmonary function testing
- Pre/post bronchodilator spirometry to detect partial/full reversibility of airflow limitation
- Pulse oximetry
CXR:
- Increased AP diameter is common
- Rule out other causes like CHF, pneumonia
- Darker lung fields can indicate emphysema (alveolar destruction), and flattening of the diaphragm from air trapping
Respiratory therapy:
- Meds: steroids, bronchodilators
- Racemic epinephrine nebulizer if stridor
- Bipap, vent for acute exacerbation
Evaluation | Patient Monitoring | Education:
- Outpatient allergy testing
- Outpatient pulmonary rehab
- Home monitoring of peak flow
- Home nebulizer
- Smoking cessation
- Pulmonary rehab
Linchpins: (Key Points)
- Recognize and treat both high CO2 and low O2.
- Both quiet/nervous and agitated/frantic can be bad signs.
- Patient may be a chronic CO2 retainer.
- Treat the factors that we can in order to manage the acute-on-chronic exacerbation.
Transcript
For more great CEN prep, got to the link below to purchase the “Emergency Nursing Examination Review” book by Dr. Laura Gasparis Vonfrolio RN, PHD
https://greatnurses.com/
References:
- Fanta, C. H. (2022, August 10). An overview of asthma management. UpToDate. https://www.uptodate.com/contents/an-overview-of-asthma-management
- Feller-Kopman, D. J. (2022, June 14). The evaluation, diagnosis, and treatment of the adult patient with acute hypercapnic respiratory failure. UpToDate. https://www.uptodate.com/contents/the-evaluation-diagnosis-and-treatment-of-the-adult-patient-with-acute-hypercapnic-respiratory-failure
- Han, M. K. (2022, September 23). Chronic obstructive pulmonary disease: Definition, clinical manifestations, diagnosis, and staging. UpToDate. https://www.uptodate.com/contents/chronic-obstructive-pulmonary-disease-definition-clinical-manifestations-diagnosis-and-staging
- Machuzak, M. S. (2020, February 18). Bronchoscopic treatment of emphysema. UpToDate. https://www.uptodate.com/contents/bronchoscopic-treatment-of-emphysema
- Quintero, D. R. (2022, October 11. ) Assessment of stridor in children. UpToDate. https://www.uptodate.com/contents/assessment-of-stridor-in-children
NCLEX
Concepts Covered:
- Circulatory System
- Emergency Care of the Cardiac Patient
- Cardiac Disorders
- Cardiovascular
- Shock
- Shock
- Disorders of the Posterior Pituitary Gland
- Endocrine
- Disorders of Pancreas
- Disorders of the Thyroid & Parathyroid Glands
- Hematology
- Gastrointestinal
- Upper GI Disorders
- Liver & Gallbladder Disorders
- Newborn Complications
- Lower GI Disorders
- Multisystem
- Neurological
- Nervous System
- Central Nervous System Disorders – Brain
- Renal
- Respiratory
- Urinary System
- Respiratory System
- Noninfectious Respiratory Disorder
- Test Taking Strategies
- Note Taking
- Basics of NCLEX
- Prefixes
- Suffixes
- Medication Administration
- Gastrointestinal Disorders
- Respiratory Disorders
- Pregnancy Risks
- Labor Complications
- Hematologic Disorders
- Fundamentals of Emergency Nursing
- Factors Influencing Community Health
- Delegation
- Perioperative Nursing Roles
- EENT Disorders
- Basics of Chemistry
- Adult
- Emergency Care of the Neurological Patient
- Acute & Chronic Renal Disorders
- Emergency Care of the Respiratory Patient
- Respiratory Emergencies
- Studying
- Substance Abuse Disorders
- Disorders of the Adrenal Gland
- Behavior
- Documentation and Communication
- Preoperative Nursing
- Endocrine System
- Legal and Ethical Issues
- Communication
- Understanding Society
- Immunological Disorders
- Infectious Disease Disorders
- Oncology Disorders
- Female Reproductive Disorders
- Fetal Development
- Terminology
- Anxiety Disorders
- Cognitive Disorders
- Musculoskeletal Trauma
- Intraoperative Nursing
- Tissues and Glands
- Vascular Disorders
- Renal Disorders
- Eating Disorders
- Prenatal Concepts
- Microbiology
- Male Reproductive Disorders
- Sexually Transmitted Infections
- Infectious Respiratory Disorder
- Depressive Disorders
- Personality Disorders
- Psychotic Disorders
- Trauma-Stress Disorders
- Peripheral Nervous System Disorders
- Integumentary Disorders
- Neurologic and Cognitive Disorders
- Integumentary Disorders
- Newborn Care
- Basics of Mathematics
- Statistics
- Labor and Delivery
- Proteins
- Emergency Care of the Trauma Patient
- Hematologic System
- Hematologic Disorders
- Developmental Considerations
- Skeletal System
- Digestive System
- Urinary Disorders
- Postpartum Care
- Basic
- Musculoskeletal Disorders
- Bipolar Disorders
- Metabolism
- Cardiovascular Disorders
- Concepts of Population Health
- Musculoskeletal Disorders
- EENT Disorders
- Postpartum Complications
- Basics of Human Biology
- Postoperative Nursing
- Neurological Emergencies
- Prioritization
- Disorders of Thermoregulation
- Writing
- Community Health Overview
- Dosage Calculations
- Neurological Trauma
- Concepts of Mental Health
- Health & Stress
- Endocrine and Metabolic Disorders
- Childhood Growth and Development
- Prenatal and Neonatal Growth and Development
- Concepts of Pharmacology
- Integumentary Important Points
- Emotions and Motivation
- Renal and Urinary Disorders
- Developmental Theories
- Reproductive System
- Adulthood Growth and Development
- Psychological Emergencies
- Growth & Development
- Basics of Sociology
- Somatoform Disorders
- Reading
- Intelligence and Language
- Oncologic Disorders
- Med Term Basic
- Med Term Whole
- Central Nervous System Disorders – Spinal Cord
- Muscular System
- Neonatal
- Learning Pharmacology
- Pediatric
- Psychological Disorders
- State of Consciousness
- Sensory System